Order Date
Account Number
Customer Name
Contact Name
Delivery Address
Post Code
Tel No
Email Address
Your Order Reference
Product Formula / Description
Special Instruction
Preferred order confirmation method  Email Phone Fax

Orders for all unlicensed products will be supplied in compliance with Regulations 167 of the Human Medicines Regulations 2012 Part 10.

Therefore please can you confirm by ticking the box below that:

The medicinal product is ordered in accordance with the specifications of a person who is a doctor, dentist nurse independent subscriber, pharmacist independent prescriber or supplement subscriber.

Is for use by a patient for whose treatment that person is directly responsible in order to fulfil the special needs of the patient.